The Patient-Driven Groupings Model (PDGM) is probably at the top of every home health agency owner’s mind in these months leading up to Jan. 1. PDGM may be a huge disruption to the industry—for those who aren’t prepared. If you are prepared, have the data you need and can focus on taking care of your clinicians and patients, everything will work out.
The Centers for Medicare & Medicaid Services (CMS) used data to arrive at the conclusions they have to enact PDGM. Therapy use brought the risk of problems, and some agencies may have overused therapy to generate revenue. Correct OASIS and diagnosis coding took a back seat in some cases because therapy visits could offset potential losses and even cost savings from having qualified and certified reviewers and nurses reviewing OASIS and providing codes.
Providers know that questionable encounters are primarily driven by just a few codes. Muscle weakness (M62.81) is well known by providers as a primary diagnosis code—it’s in the top five nationally. CMS has asked providers not to use this as a primary diagnosis for some time. CMS wants to know the underlying cause of gait abnormality (R26.9), unsteadiness on feet (R26.81) or other secondary codes. It can be argued that there isn’t always an underlying cause to muscle weakness; however, most of the time, that isn’t the case. Muscle weakness is the easy diagnosis and providers have taken the easy road for a long time.
CMS used industry data to map out the guidelines for PDGM. At the end of the day, providers gave CMS all the information it needed to develop PDGM policies.
In order for agencies to have a voice in improving PDGM, CMS needs the best data possible to influence the policy’s evolution for the better. The structure of PDGM will remain the same, but it will be adjusted, tweaked and hopefully improved. To be sure, there are still unanswered questions about the final ruling; there are some legitimate concerns. These will be eventually addressed and hopefully resolved.
Keep OASIS Out Front
With all of the focus on PDGM, it can be very easy and tempting to take your eyes off of the big picture. PDGM should be the main focus for agencies going forward. The model changes reimbursement completely and puts the focus on a few OASIS questions and up to 25 codes. However, don’t lose sight of the big picture. If you only focus on the rule changes, you can be overwhelmed and fail to make plans or progress.
Clinicians are still going to go out and gather OASIS data. There will still be coding and OASIS review. There will still be case conferences. There will still be quality assurance and performance improvement. There will still be case management. There are still visits to be made. The OASIS questions themselves haven’t changed significantly. There will continue to be revisions of OASIS—OASIS D1 is right around the corner.
As agencies prepare for the start of PDGM with so much emphasis on accurate, highly specific diagnoses codes, as well as the few functional questions currently in OASIS that determine PDGM payments, it’s important to remember the rest of OASIS. Don’t think for a minute that the rest of OASIS no longer matters much. CMS will still extract everything for its statistical analysis information and future decisions about how home health will be paid. The industry must be exceptionally diligent and thoughtful on all the OASIS questions so good data can be provided to CMS—therefore increasing the chances of good decisions from CMS.
Focus on Quality
If providers become complacent and lose sight of the parts of the OASIS that won’t affect revenue under PDGM, there is potential to get into the bad place of poor decisions from CMS based on erroneous data. And that’s not the only thing that will change with bad data. There could be alternative dispute resolutions (ADR) based on conflicting information within the OASIS. If the Functional Mobility and Goals questions within OASIS (section GG) don’t support the M1800 section, for example, imagine the ADR rulings that will result. It wouldn’t be pretty.
OASIS is a very good tool that can and should provide guidance on how to most effectively treat a patient, but only if answers to the OASIS questions paint a true picture of the situation, along with good supporting documentation. Good documentation must support the medical necessity of the treatments that will be provided and the reasons for using those treatments. Good documentation becomes better when a short summary about the patient is provided by the case manager or admitting clinician.
That summary should be short but complete and include answers to the following questions:
A summary answering these high-level questions will go a long way toward ensuring accuracy in diagnoses coding and completeness and accuracy at the detailed OASIS level.
If providers use the information to their benefit—and give the best data possible to CMS—then the rules will be adjusted to the industry’s benefit. Change is happening. Good data is the key to providing CMS the information it needs to get it right.
Don’t Forget Clinicians
The temptation is great to forget the clinicians on the front lines of homecare. The rules of reimbursement aren’t necessarily relevant to them. OASIS is still gathered; the care plan is still developed. Many clinicians won’t feel much daily impact from PDGM. However, your PDGM strategy could affect the daily interaction between nurses and patients. Providers need to make sure to keep the human element front and center. Employees should know when there are concerns. When agency owners are nervous and working scared, mistakes are made; sometimes the mistakes are costly. However, if owners help staff remain calm and stay informed and confident, things will be okay. Allow employees to take care of the patient the best way possible within the given budget, and you’ll be fine.
Using data to train staff, make decisions and care for the patients will lead agencies down the right path. Following that path will lead the industry in the right direction.
- What is the focus of care? What is the primary diagnosis on which home health will focus?
- How did the patient get in that condition, if traceable?
- What services does the agency plan to provide for the patient (e.g., skilled nursing, physical therapy, occupational therapy and home health agency services)?
- What might complicate the desired outcomes? In other words, what are all of the patient’s comorbidities, as well as other factors such as environment, etc.?